A 91-YEAR-OLD WOMAN WHO SUDDENLY TALKED MORE AND SLEPT LESS

Abstract

To the Editor: At age 91, Miss X was typically described as quiet and private. Over the course of 2 weeks, she became restless, went on shopping sprees, and talked more than usual. Often in a loud voice, she spoke incessantly about past accomplishments and her children and their families and praised God profusely. She also slept considerably less, from her usual 6 hours to a mere 2. The patient's lone home medication was alprazolam, started 10 years before for anxiety and insomnia. She had diet-controlled hypertension and no history of nicotine, alcohol, or drug abuse. A son was diagnosed with adjustment disorder; otherwise, her personal and family histories were negative for affective disorders. She remained coherent; was never disoriented; and had no hallucinations, delusions, or paranoid behavior. One night, Miss X was found wandering in her neighborhood, talking nonstop at the top of her voice. She was brought to a hospital, where physical and neurological examinations were unremarkable. Her Mini-Mental State Examination score was 30/30. Pertinent on laboratory testing were leukocytosis (11,000/μL), mild uremia (22 mg/dL), and high urinary nitrites, white blood cell count, and bacteria levels. Hemoglobin, hematocrit, liver function tests, and thyroid-stimulating hormone were all normal. Brain magnetic resonance imaging revealed age-appropriate changes. Miss X was treated with ciprofloxacin for a urinary tract infection, and started on quetiapine, haloperidol, donepezil, and memantine to manage the behavioral change. She was sent home, where she persisted in being restless, talkative, and requiring little sleep. Miss X then saw a psychiatrist, who admitted her to a psychiatric unit. All previous medications were discontinued, and lithium was initiated with excellent response. Keeping Miss X's age in mind, it was imperative to exclude delirium and dementia. It was reasonable to assume that the combination of urinary tract infection and uremia may have led to delirium, but at no point in her history was fluctuation in mental status, the central feature of delirium, observed. She also persisted in exhibiting altered behavior in spite of appropriate medical management during her first admission. With regard to dementia, Miss X never displayed genuine cognitive impairment in her history or examination. Furthermore, behavioral manifestations tend to occur in the latter stages, when memory derangement is patent and functionally limiting. Miss X's symptoms were characteristic of mania. Very late-onset (aged ≥65) mania is generally due to an underlying medical disorder, frequently neurological (e.g., tumors, stroke, injury).1 Triggering organic conditions broadly include toxic, metabolic, and infectious entities.2 Likewise implicated are drugs, such as dopamine agonists, corticosteroids, antidepressants, thyroid supplements, benzodiazepines, and antihistamines.3 Miss X was chronically taking alprazolam, which has been reported to induce mania,4,5 but the authors believe this to be an unlikely culprit because all cases described were much younger, and manic symptoms occurred within 3 weeks of treatment. After Miss X was ascertained to be free of any precipitating medical conditions, it was concluded that she was suffering from bipolar I disorder. There is a paucity of evidence on the incidence of primary bipolar disorder after the age of 90, although a profound decline is generally anticipated. Although both forms of mania (manic symptoms due to underlying medical factors and primary mania from a bipolar affective disorder) respond to drugs such as lithium, anticonvulsants, and antipsychotics, correcting the inciting condition is the management priority in secondary mania.2 Foremost in the care of patients with altered behavior is to distinguish between an organic etiology and a primary psychiatric malady. With older age comes a longer list of differential diagnosis, which makes the task of establishing the right diagnosis more challenging. Nonetheless, this case emphasizes that when faced with an older adult presenting with mania, the clinician must exclude an underlying condition before heading down the psychiatric path. Conflict of Interest: None of the authors have any financial ties or possible conflicts of interest to disclose. Author Contributions: Samala: acquired data, reviewed literature, and prepared manuscript. Chervony: edited manuscript. Ciocon: conceptualized and edited manuscript. Sponsor's Role: None.